Provider Demographics
NPI:1063456721
Name:WISDOM, ROBERT (LMLP, LCP)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WISDOM
Suffix:
Gender:M
Credentials:LMLP, LCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 747
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:KS
Mailing Address - Zip Code:66505-0747
Mailing Address - Country:US
Mailing Address - Phone:785-587-4300
Mailing Address - Fax:785-587-4377
Practice Address - Street 1:1558 HAYES DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:KS
Practice Address - Zip Code:66502-5068
Practice Address - Country:US
Practice Address - Phone:785-587-4315
Practice Address - Fax:785-587-4339
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2013-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0157101Y00000X
KS130101YA0400X
KS1438101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS856662OtherBCBS
11654652OtherCAQH
KS200441350AMedicaid